LAND, SEA AND AIR MEDICAL REVIEW SPECIALISTS

Arnold D. Panzer, MD
Diplomate American Board of Internal Medicine
Certified Medical Review Officer
Senior Aviation Medical Examiner
#16942-4

Web site: www.lsamr.com
E-mail:  lsa@lsamr.com

Phone (631) 225-3060
Fax (631) 225-3064

D.O.T. TEST VOUCHER

Date _________________

Company Name _______________________________________________________
Address _______________________________________________________
City, State  Zip _______________________________________________________
Contact Person _______________________________________________________
Contact Phone # _______________________________________________________
Employee Name _______________________________________________________
SS# or Employee ID# _______________________________________________________

Services To be Performed (please check)

Drug Testing
Pre-employment ______
Random ______
Post Accident ______
Reason to Suspect ______
Return to Duty ______
Follow-up ______
Other ______
dottest.gif (1883 bytes) Alcohol Testing
Random ______
Post Accident ______
Reason to Suspect ______
Return to Duty ______
Follow-up ______
Other ______
Physical Exam
Pre-Employment ______
Re-Certification ______
OSHA ______
Lab Work
CBC ______
Chem Panel ______
Immunizations ______
Lead Level ______
Other ______
Medications
PPD ______
Tetanus ______
Hep B ______
Other ______

910 Route 109 ° Lindenhurst, New York  11757